Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice

Abstract

Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients' health and wellbeing is instead becoming part of the problem. The way we practice medicine has become a driver for the problem. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of compromise into the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and, in our understanding of the process of research, how we generate the knowledge that informs practice. This review considers the current state of play in all 3 areas and identifies some of the work we still need to do in order to generate the practice‐based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health.

Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review

“…Recognises patient's agendas and their implications (12)(13)(14)(15)(16)(17)(18)(19) Avoids patient perceptions of abandonment (15,16), maintains hope, optimism (14) Builds patient/family TRUST through a shared sense of working for "my best interests" (23-26) Shared understanding (21) and responsibility (22) with patient and family, which may help to make defendable decisions (1 and 2).…”

“…Studies of barriers to delivering tailored person-centred prescribing reveal a number of challenges which may not be addressed by current guidelines for medicines optimisation [ 4 , 15 ]. Healthcare professionals report anxiety and a lack of confidence undertaking tailored prescribing due to a lack of support in four key areas across the system and policy level [ 4 , 16 ]. The barriers include having permission to work beyond guidelines and existing frameworks, the lack of space within their workload needed to prioritise and undertake tailored deprescribing, a lack of skills in complex decision making and the confidence to use them and performance management processes [ 4 ].…”

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

“…Research therefore describes whole-system barriers to tailored (de)prescribing practice at consultation, organisation of practices and policy levels. 21 Structural changes, such as the design of health-care systems (including workflow) and performance management tools, may require evidence that different models of care provision offer efficient, effective and equitable care. But this research also points to work 6,17 that may support individual clinicians and patients (consultation-level changes) in tackling problematic polypharmacy through tailored care.…”

“…1 Decisions involve weighing up multiple factors that vary in themselves and through interaction with each other. 21 Tailored deprescribing is therefore an example of a complex intervention, in which controlled and uncontrollable variation is inevitable and the active ingredient(s) may behave differently in varying contexts and for different people. 52 The realist review methodology is particularly useful for understanding and illuminating the relationships and impact of the interaction between the components of a complex intervention.…”

“…We have been sharing the preliminary findings of our work at clinical educational meetings including the Avoiding Harm event at the Royal College of Physicians (November 2019), 21 and within the Humber Coast and Vale CATALYST programme for new-to-practice GPs (URL: www.hyms.ac.uk/catalyst; accessed 11 March 2022).…”